Healthcare Provider Details

I. General information

NPI: 1821923129
Provider Name (Legal Business Name): LISA MARIE GRGUREVIC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2026
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16380 ROSCOE BLVD STE 100
VAN NUYS CA
91406-1221
US

IV. Provider business mailing address

26415 CARL BOYER DR STE 120
SANTA CLARITA CA
91350-5825
US

V. Phone/Fax

Practice location:
  • Phone: 833-227-3454
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: